Career stage and work setting create different barriers for evidence-based medicine


  • Maartje H.J. Swennen MD MSc,

    Corresponding author
    1. PhD Fellow, Department of Clinical Epidemiology, Division Julius Centre for Health Sciences and Primary Care, Staff Member, Directorate of Executive Board,
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  • Geert J.M.G. van der Heijden PhD,

    1. Associate Professor, Coordinator of the Epidemiology and Evidence Based Medicine Education Program, Department of Clinical Epidemiology, Division Julius Centre for Health Sciences and Primary Care,
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  • Geert H. Blijham MD PhD,

    1. Former Chairman and Vice-Dean of Executive Board, and Professor Emeritus of Internal Medicine,
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  • Cor J. Kalkman MD MSc PhD

    1. Research and Education Manager, Professor of Anesthesia, Division Perioperative and Emergency Care, and Director of Patient Safety Centre, Directorate of Executive Board, University Medical Centre Utrecht, Utrecht, The Netherlands
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Maartje H.J. Swennen, University Medical Centre Utrecht, Stratenum 6.131, Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, The Netherlands. E-mail:


Rationale, aims and objectives  Although many barriers to practising evidence-based medicine (EBM) are described, it remains poorly understood why clinicians do, and do not, incorporate high-quality evidence into their routine practice. To date, a comprehensive framework for the classification for barriers to practising EBM is lacking. This qualitative study explored the relationship between differences in career stage and work setting among doctors and their perceived barriers for practising EBM. We also explored an alternative classification of barriers.

Methods  Purposive participant sampling reflected three career stages in two different work settings: four registrars, four consultant anaesthetists and four senior anaesthetists from two departments of anaesthesiology, in an academic and a general hospital, in The Netherlands. Perceptions on practising EBM and its barriers were explored in semi-structured interviews. Using grounded theory approach, we build a framework for the classification of these barriers.

Results  In both departments, registrars and consultants demonstrated little sense of urgency to work on their EBM performance; registrars struggled with information overload and hierarchical dependence, and consultants practised confidence-based medicine. Senior doctors in both departments reported that combining clinical work with leadership tasks made them more reflective, and therefore more susceptible to the reasoning approach inherent within the current approach to EBM. They considered themselves willing and able to apply EBM, and were reported to act accordingly. Differences in setting that complicated practising EBM related to the general hospital. The absence of formal hierarchy among doctors resulted in a lack of medical consensus and an absence of integrated management teams hindered collaboration between doctors and non-medical managers. We identified 10 conditions that were conducive to the practice of EBM.

Conclusions  Both career stage and work setting were associated with perceived barriers to practising EBM. We have included these in our theoretical framework for classification of these barriers.